Laserfiche WebLink
WELL/PUMP PERMIT <br /> S;%N JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 1868 EAST HAZELTON AVENUE-STOCKTON CA 95205 - (209)468-3420 <br /> NON-REFUNDABLE PERMIT /CALL 209 953-7697 FOR INSPECTIONS EXPIRES 1 YEAR FROM DATE ISSUED <br /> JOB ADDRESS 42,4--7Cz, I Y I 1 �� CITY/ZIP m <br /> / ���1L m <br /> CROSS STREET APN �!��PARCEL SIZE2_ LAND USE APPLICATION# v <br /> n <br /> OWNER NAME (�(i( r� / 1�.1 LLr�r�,�1n� l-- PHONE.2l�l / Z7C y <br /> OWNER ADDRESS V _P al V, t CITY/STATE/ZIP l W <br /> CONTRACTOR o •� ( t ` t PHONEC( lD <br /> 1 <br /> CONTRACTOR ADDRESS v �-/ _ 'L446 CITY/STATE/ZIP R ` V d,_4/1(&i'�e, 64 \ 2u <br /> SUBCONTRACTOR �l 1 IJI;i PHONE <br /> SUBCONTRACTOR ADDRESS CITY/STATE/ZIP <br /> LICENSE -57 ❑ C-61 ❑ D-09 ❑ Other NUMBER 1041 . EXPIRATION DATE V <br /> DOMESTIC WELL SAMPLING: i General Mineral/Coliform Bacteria(4391) Dibromochloropropane(4392) i Arsenic(4393) <br /> INTENDED USE Domestic/Private ❑ Irrigation/Agricultural ❑ Industrial ❑ Water Quality Monitoring ❑ Soil Sampling/Characterization <br /> ❑ Public Water System <br /> If different from Owner: Water System Name Contact Name or Phone Number <br /> TYPE OF WORK New Well ❑ Replacement Well ❑ Well Alteration/Modification ❑ Other <br /> ❑ Monitoring Well(s) #of wells ❑ Soil Boring(s) #of borings U Geotechnical #of borings <br /> ❑ Out-Of-Service Well ❑ Out-Of-Service Well Renewal ❑ Cross-Connection Repair <br /> ❑ New Pump ❑ Pump Replacement ❑ Pump Repair ❑ Raise Well Casing <br /> WELL CONSTRUCTION <br /> Drilling Method /6-Mud Rotary ❑ Air Rotary ❑ Auger ❑ Cable Tool ❑ Push Point ❑ Other <br /> Proposed Well DepthI on Excavation )-?_ in diameter ❑ Open Bottom ❑ Gravel Pack/Gravel Size in diameter <br /> ❑ Con*rCasing in diameter / Conducctto`rr Casing Depth ft <br /> Well Casing Diamehickness/Gauge/ASTM Sched< II�ZI ❑ Steel XPlastic ❑ Stainless Steel ❑ Other <br /> Grout Seal Depthft �Q,Neat Cement(94 Ib bag/5-10 gal water) ❑ Sand Cement sack mix/7 gal water <br /> ❑ Benids) ❑ Other <br /> Grout Placement Method Pumped ❑ Free Fall ❑ Other n Retardant/Accelerator(name) <br /> PEDESTAL Installed By ❑ Driller APump Contractor ❑ Other <br /> ❑ Concrete Pedestal ❑Di ensions:Width ft Length ft Thick in ❑ Christy Box ❑ Stove Pipe <br /> PUMP ❑ Submersible❑ Turbine ❑ Other HP Pump Set ft Standing Water Level ft <br /> I HEREBY CERTIFY THAT I HAVE PREPARED THIS APPLICATION AND THAT THE WORK WILL BE DONE IN ACCORDANCE WITH SAN <br /> JOAQUIN COUNTY ORDINANCES, STATE LAWS, AND RULES AND REGULATIONS. I ALSO CERTIFY THAT MY REQUIRED LICENSE IS <br /> CURRENT AND ACTIVE WITH THE CALIFORNIA CONTRACTORS STATE LICENSE BOARD AND THAT I AM IN COMPLIANCE WITH ALL <br /> WORKERS COMPENSATION LAWS. <br /> MINIMU UR ADVANCE NOTICE REQUIRED FOR INSPECTIONS -PLEASE CALL (209) 953-7697 (` <br /> SIGNED TITLE ��t �—`� DATE <br /> 4,71 <br /> IF- <br /> Q /N <br /> THVf MA <br /> N L <br /> N <br /> DE ARTMENT SE ONLY <br /> Application Accepted By Date Pt Area Employee ID# <br /> *Melaqh <br /> Grout Inspection By Date :.?:::!&A4 SPECIAL Well Permit <br /> Pump Inspection By Date ❑ WAIVER Received <br /> Soil Boring Inspection By Date Constructed Well Depth LOO <br /> CO ME TS <br /> a <br /> PE SC Received Amount Permit/ <br /> Codes Info B Cash emitted Date Service Request#411 �Z-['Z4 Invoice# Well ID# <br /> 21 <br /> 2v <br /> C> Z. <br /> EHD 43-06 8/01/16 WELL/PUMP PERMIT <br />